Introduction

Oral antifungal drugs currently in use include itraconazole, fluconazole, ketoconazole and
terbinafine. They are reserved for extensive or severe infection for which topical antifungal agents
are inappropriate or ineffective, because of high cost, potential side effects and drug interactions.
Griseofulvin is not discussed as it is no longer available in New Zealand. Nor is nystatin, as it is
only appropriate for intestinal candidiasis. Voriconazole has recently become available but is
reserve for the treatment of serious and refractory fungal infections in hospitalised patients.
Itraconazole
Oral itraconazole (Sporanox) is a very useful broad spectrum antifungal drug. It should be taken
after a fatty meal, preferably with an acidic drink such as orange juice.
Dosing regimes depend on the skin condition, its duration and severity, and need for prophylaxis.
For example:
Skin infections: 200 mg daily for one to four weeks
Vulvovaginal candidiasis: 200 mg twice daily for one day OR 200 mg daily for 3 days,
repeated if necessary or regularly once-weekly to once-monthly
Oral candidiasis: 100 mg daily for two weeks
Onychomycosis: 200 mg/day for 6-8 weeks (fingernails) or 3-4 months (toenails), OR 200
mg twice daily for 7 days, repeated monthly for 2 months (fingernails) or 3-4 months
(toenails)
Nausea is the most common side effect. Abnormal liver function tests affect 5% of those on long
term therapy but are rarely severe (monitoring is recommended for prolonged courses). It has
been reported to cause congestive cardiac failure and serious rashes. The main concern with
azoles is serious interactions with other medications.
As itraconazole needs acid for its absorption, antacids, H2 antagonists and omeprazole should not
be taken for 2 hours after itraconazole.
These drugs should not be taken by those on itraconazole:
Cisapride
HMG Co-A reductase inhibitors (atorvastatin, lovastatin, simvastatin) the interaction may
cause heart failure; fluvastatin and pravastatin are acceptable alternatives.
Midazolam, triazolam
The antihistamines astemizole and terfenadine (withdrawn from New Zealand market)
The dose of these drugs should be reduced:
Warfarin
Digoxin
Methyl prednisolone
Ciclosporin
Tacrolimus
Vinca alkaloids
The dose of these drugs may need reducing if side effects arise:
Quinidine
Calcium channel blockers
Antidiabetic sulphonylureas
The following drugs decrease the concentration of itraconazole:
Rifampicin
Isoniazid
Phenytoin
Carbamazepine
Itraconazole is not thought to interact with the oral contraceptive pill and must be avoided in
pregnancy.
Fluconazole
Fluconazole (Diflucan) is a triazole used for candidiasis and cutaneous dermatophyte infections.
It is not registered for nail infections. The dose and duration depends on the nature and severity of
infection. Typically:
Oropharyngeal candidiasis: 50mg daily for 7-14 days
Vaginal candidiasis: 150 mg single dose
Dermatomycoses: 150 mg once weekly for 2 to 6 weeks
The main contraindication is concomitant administration with cisapride. It should be avoided in
pregnancy / lactation and in the presence of electrolyte abnormalities, heart disease and renal
impairment.
Side effects include:
GI disturbance
Rashes including urticaria, exfoliative dermatitis
Arrhythmias
Hepatotoxicity
Drug interactions are similar to those for itraconazole. Refer to a current prescribing text.
Ketoconazole
Ketoconazole (Nizoral) is used to treat fungal infections where other treatments have failed or
are contraindicated. It is effective for yeasts and dermatophytes and is usually prescribed in a
daily dose of 200mg after food.
Its main concern is hepatic liver function should be monitored. The incidence of significant
hepatitis is about 1:1500, much higher than with itraconazole. It has similar interactions with
other drugs.
Terbinafine
Terbinafine can be taken with or without food. Listed side effects include:
GI upset
Rashes including urticaria, toxic epidermal necrolysis
Arthralgia & myalgia
Taste disturbance
Hepatobiliary dysfunction
Leukopaenia
Drug interactions are not as frequent or as serious as with itraconazole. However, interactions are
reported with tricyclic antidepressants, beta-blockers, SSRIa, MAOIs, hepatic enzyme inhibitors
(cimetidine) or inducers (rifampicin) and possibly with oral contraceptives.







Pityriasis versicolor
Learning objectives
Introduction
Differential diagnosis
Investigations
Management
Other conditions due to malassezia
Activity
Learning objectives
Identify and manage pityriasis versicolor
Introduction
Although often called tinea versicolor this name is incorrect, as pityriasis versicolor is not due to
dermatophyte fungi.
Pityriasis versicolor presents as asymptomatic flaky patches on the trunk, neck, and/or arms,
which persist for months or years. It is pink or coppery in pale subjects, but on tanned skin the
patches are pale brown, since tanning does not occur in the affected areas. The yeast produces
azelaic acid, which diffuses down and impairs the function of the melanocytes.
Pityriasis versicolor is more common in hot, humid climates or in those who sweat heavily, so it
may recur each summer.
Pityriasis versicolor
Brown
patches
White
patches
Pink
patches
Differential diagnosis
Pityriasis versicolor may be confused with:
Dry discoid eczema (irritable, generally scattered on trunk and/or limbs)
Guttate psoriasis (red scaly plaques, look for psoriatic lesions elsewhere)
Idiopathic guttate hypomelanosis (affects shins and forearms, due to photoageing)
Pityriasis alba (large patches on face and upper arms)
Pityriasis rosea (short history and rapid onset)
Postinflammatory hypo- or hyper-pigmentation (irregular distribution, prior inflammatory
episode)
Seborrhoeic dermatitis (distribution includes scalp and face)
Tinea corporis (slowly extending annular plaques)
Vitiligo (completely white or trichrome asymmetrical macules)
Investigations
The diagnosis of malassezia infections is generally confirmed by skin scrapings but malassezia may
also be identified in apparently normal skin. Microscopy of potassium hydroxide (KOH)
preparations from pityriasis versicolor shows clusters of yeast cells and long hyphae. The
appearance is said to be like spaghetti and meatballs.
Malassezia species are difficult to grow in the laboratory so scrapings may be reported as culture
negative. The yeast is lipophilic so long-chain fatty acids must be added to the media.
Seven species have been isolated to date there is some controversy as to whether specific
species cause different skin diseases.
M. furfur
M. sympodialis
M. globosa
M. obtusa
M. restricta
M. slooffiae
M. pachydermatis
M. ovalis (also known as Pityrosporum ovale)
Pityriasis versicolor fluoresces blue-green on examination using a Wood's lamp (long wavelength
UVA1).
It is sometimes observed in the stratum corneum of skin biopsies and stains prominently with PAS.
Microscopy of malassezia

Management
Available treatments for pityriasis versicolor include topical agents applied for about 2 weeks.
Advise the patient that the first aim is to clear up scaling and that it may take some weeks or
months for the skin colour to return to normal. Recommend washing affected areas with an anti-
dandruff shampoo twice weekly to reduce the chance of relapse. Treatment may be repeated as
required.
Propylene glycol
Sodium thiosulphate solution
Selenium sulphide
Topical Oral azoles including clotrimazole, miconazole, econazole and ketoconazole in
various formulations
Terbinafine gel
Ciclopirox cream/solution
Patients with extensive or persistent pityriasis versicolor may be prescribed ketoconazole tablets
or itraconazole capsules, 200mg daily for 7-10 days and prophylactically once each month.
Specialist approval is required for PHARMAC subsidy.
Other conditions due to malassezia
Several other skin conditions are associated with proliferation of malassezia, especially with the
predisposing factors of humidity, sweating and seborrhoea. They include:
Pityrosporum folliculitis (superficial acne-like eruption on upper trunk)
Pityriasis capitis (dandruff)
Seborrhoeic dermatitis (non-pruritic scaly red patches on face, scalp and flexures)
Facial atopic dermatitis, in some cases.






Tinea pedis
Learning objectives
Clinical features
Management
Activity
Learning objectives
Identify and manage tinea pedis
Clinical features
Tinea pedis is most frequently due to Trichophyton rubrum, T. interdigitale (formerly known as T.
mentagrophytes var. interdigitale) or Epidermophyton floccosum. Tinea pedis has various patterns
and may affect one or both feet.
Chronic hyperkeratotic tinea refers to patchy fine dry scaling on the sole of the foot
Moccasin tinea is hyperkeratotic tinea affecting the skin of the entire sole, heel and sides
of the foot
Athlete's foot refers to moist peeling irritable skin between the toes, most often in the cleft
between the fourth and fifth toes. It is not always fungal in origin and is often associated
with bacterial infection and irritant dermatitis
Clusters of blisters or pustules on the sides of the feet or insteps are confused with
pompholyx eczema
Round dry patches on the top of the foot may appear similar to psoriasis
Tinea pedis is more common in adults than in children and frequently recurs after initially
successful treatment with topical antifungal agents because of reinfection. Fungal spores can
persist for months or years in bathrooms, changing rooms and around swimming pools.
Tinea pedis

Localised hyperkeratosis Cluster of blisters Moccasin tinea pedis

Athlete's foot (pseudomonas) Athlete's foot (tinea)
in a diabetic patient
Extensive scaling
Management
First confirm the diagnosis of tinea (scrapings and clippings) and look for other sites of infection
(groin, nails). Consider alternative explanations including:
Bacterial infection (Staph exudative; gram negative organisms green; anaerobes
malodorous)
Dermatitis (intensely itchy and scratched, associated with rash elsewhere e.g. atopic
flexural eczema; contact allergy corresponding with shoe material)
Psoriasis (hyperkeratotic, non-itchy, often signs elsewhere such as scalp, elbows, knees,
flexures, nails)
Corns (pressure areas, painful)
Mild and localised tinea pedis can be managed with education and topical antifungal agents. Tell
the patient to hot wash socks and stockings, and to wipe out shoes with formalin or meths
solution. They should be advised that the condition is mildly contagious, and to wear sandals in
changing rooms and not to share towels and footwear. It is likely to recur, so suggest they dry
carefully and apply an antifungal powder after bathing long term.
There are numerous topical antifungal agents, of which terbinafine cream (Lamisil) is probably
the most effective. Fully funded options in New Zealand (April 2005) are:
Clotrimazole cream
Econazole cream
Miconazole cream
Whitfield's ointment is also effective (benzoic acid 6%, salicyclic acid 3% in emulsifying ointment).
Resistant and extensive culture-confirmed cases of tinea pedis will require oral therapy for one to
four weeks, usually with terbinafine or itraconazole (the latter requires specialist approval for
PHARMAC subsidy).
Confirmed tinea unguium may require oral antifungal agents for 3 months or longer if the infection
is clinically significant and there are no contraindications to treatment. Cure rates depend on the
severity of infection, the infecting organism, comorbidities and the age of the patient.